Body dysmorphic disorder (BDD) is a mental disorder that involves a distorted body image. It is generally diagnosed in those who are extremely critical of their physique or self-image, despite the fact there may be no noticeable disfigurement or defect.

Most people wish they could change or improve some aspect of their physical appearance, but people suffering from BDD, generally considered of normal or even attractive appearance, believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation at their appearance. They tend to be very secretive and reluctant to seek help because they are afraid others will think them vain or they may feel too embarrassed to do so.

Ironically, BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite; people with BDD believe themselves to be irrevocably ugly or defective.

BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders among psychologists. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

A German study has shown that 1-2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (Psychological Medicine, vol 36, p 877). Chronically low self-esteem is characteristic of those with BDD, due to the value of oneself being so closely linked with one's perceived appearance. The prevalence of BDD is equal in men and women, and causes chronic social anxiety for those suffering from the disorder[3].

Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with clinical depression and three times as high as those with bipolar disorder[1]. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery[2]. A similar disorder, Gender identity disorder, where the patient is upset with his or her entire sexual biology, often precipitates BDD-like feelings being directed specifically at external sexually dimorphic features, which are in constant conflict with the patient's internal psychiatric gender. This high rate of comorbidity of BDD in GID patients results in an estimated suicide attempt rate of 20%; the suicide attempt rate for patients with only BDD is 15%.[3][4]

Contents

History

In 1886, BDD was first documented by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first truly recognized by the American Psychiatric Association in 1987, and in 1997, BDD was first recorded and formally recognized as a disorder in the DSM.

In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; RussianaristocratSergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

Diagnoses

According to the DSM IV, to be diagnosed with BDD, a person must possess the following criterion:

"Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive."

"The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning."

"The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)."[5]

Obsession with plastic surgery or multiple plastic surgeries, with little satisfactory results for the patient.

In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results. Patients have even tried to remove undesired features with a knife or other such tool when the center of the concern is on a point, such as a mole or other such feature in the skin.

(The percentages add up to more than 100% because patients with BDD are usually concerned with more than one aspect of their appearance.)

Development

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others.

An absolute cause of body dysmorphic disorder is unknown. However research shows that a number of factors may be involved and that they can occur in combination, including:

A chemical imbalance in the brain. An insufficient level of serotonin, one of the brain's neurotransmitters involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary.

Obsessive-compulsive disorder. BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over their life. A history of, or genetic predisposition to, OCD may make people more susceptible to BDD.

Generalized anxiety disorder. Body dysmorphic disorder may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD.

The Disabling Effects of BDD

BDD can be anywhere from slightly to severely debilitating. It can make normal employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners of sufferers of BDD may also become involved and suffer greatly, sometimes losing their loved one to suicide.

Sufferers of BDD may often find themselves getting almost 'stuck' in moping around. That is to say that sufferers, with such a type of depression, can in some cases appear to take a long time to get everything done. However, this is not actually the case, as it is simply that the BDD sufferers will often just sit or lie down for prolonged time periods of time, without being able to actually motivate themselves until it becomes completely necessary to get back up. This can often cause little to get done by sufferers, and they can have little self motivation with anything, including relationships with other people. However, contrary to this, when the action is relevant to the person's image, it is more common for the sufferer to exhibit a fanatic and extreme approach, applying their attention fully to self-grooming/ modification.

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist unless treated.

Prevalence

Studies show that BDD is common in not only nonclinical settings, but clinical settings, as well. A study was done of 200 people with DSM-IV Body Dysmorphic Disorder. These people were of age 12 or older and were available to be interviewed in person. They were obtained from mental health professionals, advertisements, the subject’s friends and relatives, and non-psychiatrist physicians. Fifty-three subjects were receiving medication, 33 were receiving psychotherapy, and 48 were receiving both medication and psychotherapy. The severity of BDD was assessed using the Yale-Brown Obsessive Compulsive Scale modified for BDD, and symptoms were assessed using the Body Dysmorphic Disorder Examination. Both tests were designed specifically to assess BDD. Results showed that BDD occurs in 0.7% - 1.1% of community samples and 2%-13% of nonclinical samples. 13% of psychiatric inpatients had BDD.[6] Studies also found that some of the patients initially diagnosed with OCD had BDD, as well. 53 patients with OCD and 53 patients with BDD were compared in a study. Clinical features, comorbidity, family history, and demographic features were compared between the two groups. Nine of the 62 subjects (14.5%) of those with OCD also had BDD.[7]

In most cases, BDD is under diagnosed. In a study of 17 patients with BDD, BDD was noted in only five patient charts, and none of the patients received an official diagnosis of BDD despite the fact that it was present.[8]

Treatments

Studies have found that the psychodynamic approach to therapy, traditional talk therapy, has not been proven effective in treating BDD. However, Cognitive Behavior Therapy (CBT) has proven more effective. In a study of 54 patients with BDD who were randomly assigned to Cognitive Behavior Therapy or no treatment, BDD symptoms decreased significantly in those patients undergoing CBT. BDD was eliminated in 82% of cases at post treatment and 77% at follow-up. (8) Due to low levels of serotonin in the brain, another commonly used treatment is SSRI drugs (Selective Serotonin Reuptake Inhibitor). 74 subjects were enrolled in a placebo controlled study group to evaluate the efficiency of fluoxetine hydrochloride, a SSRI drug. Patients were randomized to receive 12-weeks of double-blind treatment with fluoxetine or the placebo. At the end of 12 weeks, 53% of patients responded to the fluoxetine.[9]

Body Dysmorphic Disorder is a chronic disease that has symptoms that never subside. Instead, they get worse as time goes on. Without treatment, BDD could last a lifetime. In many cases, as illustrated in The Broken Mirror by Katharine Phillips, the social lives of many patients disintegrates because they are so preoccupied with their appearance.[10]

The film “Looks that Kill” features a patient who was treated at the Priory Hospital North London. The video is available from Films of Record tel.: +44(0)20 7286 0333

External links

F.E.A.S.T.'s Eating Disorders Glossary, a comprehensive online eating disorders dictionary with more than 400 terms and concepts used in diagnosis and treatment of eating disorders, disturbances and associated conditions like body dysmorphic disorder.